198603458-9-19-2023-28-AS-VMAO-CVTVSP-20230919164153

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603458
Report Date: 09/19/2023
Date Signed: 09/19/2023 04:42:02 PM

Document Has Been Signed on 09/19/2023 04:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ARS FOUNTAIN HOMES		FACILITY NUMBER:	198603458
ADMINISTRATOR:	SANTOS JR., APOLONIO C.		FACILITY TYPE:	740
ADDRESS:	2668 FAWN CIRCLE		TELEPHONE:	(909) 575-7612
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	6	CENSUS: 3	DATE:	09/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Luis Gabriel Santos- Asst. Administrator		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Care Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA met with Assistant Administrator, Luis Gabriel Santos, and explained the purpose for the visit. The facility is licensed to serve (6) elderly adults, ages 60 and over. It is approved for (6) non-ambulatory residents, of which (2) may be bedridden in room#3 only, and has a Hospice Waiver approved for (6). The facility is a single-story home, located in a residential area. The home consists of a living room, (4) residents bedrooms, (1) staff room, (2) resident bathrooms, a kitchen, dining room, attached garage, and shaded patio with seating in the backyard. The following (12) CARE tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention. During today's visit, LPA Maldonado obtained a copy of the client and staff roster, and conducted a tour of the physical plant with assistance of caregiver Melba Honrada. The following was observed: There is one central entry point for universal entry screening. The facility has a Mitigation Plan and Infection Control Plan approved and in place. There is sufficient PPE stored for 30-days and readily available for use, throughout the home and stored in the garage. The physical plant inside and outside is clean, sanitary and in good repair. All walkways, pathways, and ramps were observed to be free of obstruction/hazards. All resident rooms were inspected and observed to have the required furniture, bedding, linens, chair, adequate lighting, and closet space. At 12:50PM, LPA observed (2) resident beds to have full bed rails and (1) resident bed had half bed-rails. Each restroom was equipped with a toilet, shower, and wash basin. The restrooms had the required grab bars and non-skid mats. All kitchen and laundry equipment was observed clean and operational during today's visit. (Report Continued on LIC809-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARS FOUNTAIN HOMES	FACILITY NUMBER: 198603458
	VISIT DATE: 09/19/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The water was tested and measured at 117.3*F in bathroom# 1 and 116.6*F in bathroom# 2, which is in compliance. The facility food was inspected and was observed to be sufficient for the amount of residents in care. The requirement was met for 2-day perishables and 7-day non-perishables available. One refrigerator inside the home and another freezer in the garage were observed fully stocked with a variety of nutritious foods. Kitchen cabinets and the garage were observed with a variety of non-perishables including vegetables, proteins, and cereals. Emergency disaster plan, personal rights and complaint procedures are posted as required. The smoke and carbon monoxide detectors were tested and observed to operate properly. Fire extinguishers were observed in the dining room and in the hallway, with current inspections and were noted to be fully charged. There is a working telephone in the facility for residents to use. No bodies of water were located on the premises. There is adequate seating in common areas for the licensed capacity. Cleaning supplies/toxins were observed stored and locked under the kitchen sink and in the laundry room, inaccessible to residents. Auditory devices were observed to be operational during the visit at each entry/exit. Sharps were observed stored in a kitchen cabinet, locked and inaccessible to residents.
At 2:30PM, (3) resident files were reviewed. LPA discovered that the files for residents# 1-3 (R1-R3) were missing written orders for the bed rails, indicating the need for it, and files for R2-R3 were missing a Needs and Services Plan. R1's file was also missing their hospice care plan and has no updated medical assessment or appraisal, as required on an annual basis for residents with dementia.
Medications and Medication Administration Records (MARs) were reviewed for (3) residents and observed to be documented properly and administered as prescribed.
At 3:00PM, (4) staff files were reviewed. LPA discovered that the file for Staff# 1-3 (S1-S3) were missing proof of completed orientation and required annual training, the file for S4 was missing verification that they meet the educational requirements for Administrator, and proof of health screenings for S1, S2, and S4 were not located in their files. Interviews with S1-S3 were conducted and LPA was unable to conduct interviews with R1-R3 due to residents sleeping and/or having visitors at the time.

Per California Code of Regulations, Title 22, deficiencies were observed during today's visit and will be cited on the LIC809-D.

An exit interview was conducted with Assistant Administrator, Luis Gabriel Santos, and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 09/19/2023 04:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARS FOUNTAIN HOMES	FACILITY NUMBER: 198603458
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(6)(A)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (A) For administrators this shall include verification that he/she meets the educational requirements in Section 87405(d) through (g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in the file for the administrator did not have the required verification indicating they meet the educational requirement, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Licensee will submit a copy of the Adminstrator's verification that they meet the educational requirement, to LPA, via email by the POC due date.

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 of 4 staff's health screenings not maintained in their file, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Licensee will provide a copy of the health screenings for S1, S2, and S4, to LPA via email, by the POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 09/19/2023 04:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARS FOUNTAIN HOMES	FACILITY NUMBER: 198603458
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in3 of 3 resident files missing written orders from a physician, indicating the need for bed rails, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Licensee will obtain written orders from R1-R3's physician/hospice agency, indicating the need for the bed rails and will email to LPA, by the POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 09/19/2023 04:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ARS FOUNTAIN HOMES	FACILITY NUMBER: 198603458
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(c)

87412(c) Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 of 4 staff not having proof of required annual training and orientation available in their file, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of required annual training and orientation for Staff# 1-3, to LPA via email, by the POC due date.

Type B

Section Cited

CCR

87705(c)(5)

87705(c)(5) Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 of 3 residents with dementia without an updated medical assessment and appraisal, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Licensee will obtain an updated medical assessment and appraisal for R1, as required. Proof will be sent to LPA via email by the POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5